"We also encourage HHS to work with a broader set of stakeholders to understand which levers may have the biggest impact on health equity, especially when myriad health equity issues are … outside the control of QHPs," noted one rule respondent
HHS put health equity front and center in its annual Notice of Benefit and Payment Parameters (NBPP) rule for the marketplace. Two proposals would require plans to include healthcare disparities in their Quality Improvement Strategies (QIS) and become accredited in health equity. HealthLeaders examines these proposals—including HHS' associated request for equity data insights—and payer stakeholder response. Of note is a question that is not new to the rule and the responses it triggered: how will health equity be operationalized across healthcare's delivery and reimbursement systems?
Aligning equity and quality
If finalized, the disparities QIS inclusion would begin in 2023 and would be in addition to another ACA-required topic of each plan’s choosing: improving health outcomes, preventing hospital readmissions, improving safety and reducing medical errors, or promoting wellness and health. Per the NBPP, the QIS is intended to be a "continuous improvement process" that health plans use to define needs, set goals, and design incentives to help achieve. A CMS fact sheet notes that "[i]n PY2020, an estimated 60% of QHP issuer QIS submissions … did address health care disparities."
Health equity data, measures, and accreditation
Like all stakeholders, HHS is eager to develop a data-driven understanding of social determinants of health (SDOH) that improves clinical and non-clinical outcomes. In the NBPP, the agency requires plans to submit five new data variables while requesting input on broader SDOH data types, their value, collection barriers, and related incentives. Payer response to these five variables—ZIP code, race, ethnicity, and Individual Coverage Health Reimbursement Arrangement (HRA) and subsidy indicators—and how they would be used is discussed in this HealthLeaders article.
HHS desires balance between population-based and individualized SDOH programs and seeks to understand obstacles that impact payer equity accountability. A few of its questions from the rule include:
- "What health conditions or outcome variables should CMS analyze to identify gaps in … health care services?
- What are some of the ways that CMS could measure QHP issuers' progress toward advancing health equity?
- Are there ways that CMS could incentivize QHP issuers to advance health equity outside of the QHP certification requirement, such as through other federal reporting requirements, including MLR reporting?"
Payer response
The payer community naturally supports health equity, with their NBPP responses ranging from "spirit of the law" support for NCQA Health Equity accreditation to noting state-based nuances that prohibit select SDOH data collection. The following summarizes notable quotes and/or recommendation from nine of the largest health plans or plan associations. Note: While Blues plan operator Health Care Services Corporation (HCSC) did submit a comment letter, it largely agreed with the Blue Cross Blue Shield Association (BSBSA) and commented only on risk provisions.
Association for Community Affiliated Plans (ACAP)
"Addressing challenges related to health equity … will require an enterprise-wide engagement for plans to take advantage of all policy and operational levers that they have at their disposal, across multiple lines of business. We expect to have additional information for CMS on these topics as the project continues to evolve."
One of AHIP's recommendations illustrates the complexity of the linkage between healthcare services, outcomes, and reimbursement:
"Social determinants interventions are not considered 'medical services' under medical loss ratio (MLR) calculations and thus are counted as administrative costs. Allowing issuers to treat SDOH interventions as medical services would allow issuers flexibility to address the social needs of enrollees to reduce the upstream causes of healthcare disparities, encourage investment in addressing SDOH, and promote the sustainability of these interventions."
The statistic that health outcomes are 20% clinical and 80% non-clinical has helped put SDOH on the map. But only by officially classifying its interventions as "medical" will health plans realize an MLR-based incentive to deliver.
To other payer community SDOH data recommendations, Anthem adds the United States Core Data for Interoperability (USCDI). The USCDI July 2021 update included the addition of SDOH to three of 19 data classes/elements:
- Assessment and Plan of Treatment should include assessment of SDOH risk
- Problems (documented condition, diagnoses, or event) should include SDOH conditions, including those identified via ZIP code
- Procedures should include SDOH-based services
Blue Cross Blue Shield Association (BCBSA)
In addition to USCDI, BCBSA also recommends Gravity Project SDOH data collection and standardization as a "a multi-industry effort to reduce current barriers to integration of social risk data into clinical decision-making to improve health outcomes." AHIP had recommended the CDC’s Social Vulnerability Index (SVI).
Centene summarizes well the "common challenge for all insurers," namely the "lack of interoperable data infrastructure and inconsistent data standards, as well as low consumer response rates, [that] make it difficult to obtain and utilize the data necessary to readily identify how inequities are impacting our most vulnerable members."
While not supporting health equity certification, Cigna notes that it is currently pursuing NCQA Health Equity Accreditation for its California marketplace plans (offered on the nation's first state-based exchange).
CVS Health made the important point that health plans alone cannot achieve equity: "We also encourage HHS to work with a broader set of stakeholders to understand which levers may have the biggest impact on health equity, especially when myriad health equity issues are inherently tied to the provider workforce, the social safety net and other social issues, and are therefore outside the control of QHPs."
Kaiser indicated its "strong support" for including disparities as a required QIS element. Other plans recommended delayed implementation or argued that health equity could not be siloed from other quality dimensions. Kaiser further recommended that NCQA accreditation be optional and noted in marketplace listings to test its influence on consumer decisions.
UnitedHealthcare (UHC)
UHC stated that it would "welcome NCQA's new Health Equity Accreditation as a means to measure and demonstrate the impact of our programs." It specifically identified its SDOH data sources (Monthly Membership Report, Full Enrollment Data File, 834, and other supplemental files as well as provider data), but identified their limitations.
In general, payers are an informed community—helping to lead the way through their regulatory responses and initiatives like the Strategic Health Information Exchange Collaboration (SHIEC). The SHIEC is participating in the aforementioned Gravity Project from H7, which is also facilitating a Bulk FHIR interoperability standard that allows "push button" access to population health data that will "change what payers expect from providers."
Operationalizing health equity
Organizations like the Institute for Healthcare Improvement (IHI) predict more outcomes-based measurement, SDOH data stratification, and public reporting. Conversely, there is still the question of whether health equity should be a distinct dimension of health outcome categories or embedded within all. While the Institute of Medicine and some payers argue that equity cannot standalone, current IHI leadership has begun to suggest that health equity—in addition to "workforce well-being and safety"—are distinct parts of a new Quintuple Aim of healthcare.
Given these and other factors, expect extensive revisions to the NBPP rule before HHS finalizes it in May 2022. As a result of payer feedback, the agency is highly likely to delay requiring additional SDOH data collection or health equity accreditation.
Laura Beerman is a contributing writer for HealthLeaders.
KEY TAKEAWAYS
Payer responses to HHS health equity proposals reflect a community that is dedicated to the cause and knows not only its limitations but the diverse industry experts and levers that are necessary for better outcomes.
There is much work to be done to address data privacy, security, collection, and standardization—for social determinants of health and many other variables.
It is highly unlikely that HHS will finalize all of its requirements as broader questions are raised about operationalizing health equity.